Information Collection

Technical Assistance Program - American Indian Tribes

IC 193387 under ICR 201307-0572-003 · OMB 0572-0112.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0572-0112 can be found here:

Documents and Forms

Document Name Document Type
Form AD 1047 Technical Assistance Program - American Indian Tribes Form and Instruction
AD 1047 Certification Regarding Debarment AD 1047.pdf www.usda.gov/rus/water/wwforms.htm Form and Instruction
AD 1048 Certification Regarding Debarment - Lower Tiered AD 1048.pdf www.usda.gov/rus/water/wwforms.htm Form and Instruction
AD 1049 Certification for a Drug Free Workplace AD 1049.pdf www.usda.gov/rus/water/wwforms.htm Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Technical Assistance Program - American Indian Tribes	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 7 CFR 1775

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	AD 1047	Certification Regarding Debarment	AD 1047.pdf	http://www.usda.gov/rus/water/wwforms.htm	Yes	No	Fillable Printable
Form and Instruction	AD 1048	Certification Regarding Debarment - Lower Tiered	AD 1048.pdf	http://www.usda.gov/rus/water/wwforms.htm	Yes	No	Fillable Printable
Form and Instruction	AD 1049	Certification for a Drug Free Workplace	AD 1049.pdf	http://www.usda.gov/rus/water/wwforms.htm	Yes	No	Fillable Printable

Line of Business: Economic Development

Subfunction: Business and Industry Development

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	279	-90	-7	376
Annual IC Time Burden (Hours)	981	-109	72	1,018
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.